Download STOPP START Toolkit Supporting Medication Review

STOPP START Toolkit
Supporting
Medication Review
STOPP:
Screening Tool of Older People’s potentially
Every effort has been made to ensure the information in this
document is current and correct at the time of publication,
however errors may have occurred and data for individual
drugs, national or local guidance may have changed. Where
there is any doubt, information should be checked against
manufacturers’ recommendations, published literature or other
specialist sources.
Medicines Management Team
NHS Cumbria
01228 608316
February 2013
28
inappropriate Prescriptions.
START:
Screening Tool to Alert doctors to Right
i.e. appropriate, indicated Treatments.1
References
STOPP: Screening Tool of Older People’s
potentially inappropriate Prescriptions.
1
1. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP
(Screening Tool of Older Persons’ Prescriptions) and START (Screening
Tool to Alert Doctors to Right Treatment): Consensus Validation. Int J Clin
Pharmacol Ther 2008; 46(2): 72 – 83. PMID 18218287
Prescriptions that are potentially inappropriate in
persons aged ≥ 65 years of age
PAGE
4
Introduction
Gastrointestinal System
8
Cardiovascular System
10
Respiratory System
14
Central Nervous System
2. Task Force on Medicines Partnership. Room for Review. A guide to
medication review: the agenda for patients, practitioners and managers.
Medicines Partnership. London. 2002
3. Beers MH. Explicit Criteria for Determining Potentially Inappropriate
Medication Use by Elderly. An Update. Arch Intern Med. 1997;157:15311536
4. British National Formulary available from: www.bnf.org
16
5. NHS Cumbria Medicines Management Information available from:
www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/
Home.aspx
6. Guthrie et al. High risk prescribing in primary care patients particularly
vulnerable to adverse drug events: cross sectional population database
analysis in Scottish general practice. BMJ 2011; 342;d3514
7. Pirmohamed M et al. Adverse drug reactions as cause of admission to
hospital: prospective analysis of 18,820 patients. BMJ 2004; 329; 15-17
Endocrine System
20
Urogenital System
22
9. Boustani M et al. Impact of anticholinergics on the aging brain; a review and practical application. Aging health. 2008; 4:3; 311-20
Musculoskeletal System
24
10. Polypharmacy Action Group. NHS Highland; Polypharmacy:Guidance
for prescribing in frail adults. Nov 11
8. Howard R et al. Which drugs cause preventable admissions to hospital?
A systematic review. Br J Clin Pharmacol 2006; 63:2; 136-147
11. NICE Guidance available from: www.nice.org.uk/guidance/
index.jsp
Miscellaneous
26
12. SIGN Guideline 95 Heart failure, annex 5
13. MHRA Drug Safety Updates and alerts available at
www.mhra.gov.uk
2
27
START: Screening Tool to Alert doctors to Right
Wound Management
Local Wound Management Prescribing Guidelines are available from the
Medicines Management intranet pages.5
If after using a silver product for 1-2 weeks, no improvement in the
wound is seen, then a full reassessment of the wound and patient should
i.e. appropriate, indicated Treatments.1
Medication that should be considered for people ≥ 65
years of age where no contraindication exists
be undertaken.
PAGE
Anticholinergic Burden Scale (ACB)9
A total score of three or more is considered clinically relevant. More
scores are given in appendices of the practice guide to clinical medication
review.
5
Gastrointestinal System
9
Cardiovascular System
13
Respiratory System
15
Score 1
Score 2
Score 3
Alverine
Amantadine
Belladonna alkaloids
not otherwise listed
Carbamazepine
Central Nervous System
19
Atenolol & most betablockers
Bupropion
Amitriptyline & most
TCAs
Atropine
Endocrine System
21
Chlorthalidone
Cyproheptadine
Chlorphenamine and
sedating antihistamines
Dicylomine
Cimetidine & H2RAs
Urogenital System
23
Codeine & other opiates
Methotrimeprazine
(Levomepromazine)
Oxcarbazepine
Diazepam & BZDs
Pethidine
Digoxin
Pimozide
Furosemide & other diuretics
Cetirizine & nonsedating antihistamines*
Loperamide*
Haloperidol
Doxepin and others
related to TCAs
Hyoscine
(scopolamine)
Olanzapine and most
atypicals
Orphenadrine
Oxybutynin and
most incontinence
drugs
Paroxetine and most
SSRIs
Musculoskeletal System
References
27
*From NHS Scotland Polypharmacy Guidance Oct 2012
26
25
3
An evidence based approach to
Musculoskeletal System
prescribing in the elderly.
BNF Chapter 10
START
Introduction
A definition of medication review is “a structured, critical examination of
a patient’s medicines with the objective of reaching an agreement with
the patient about treatment, optimising the impact of medicines,
minimising the number of medication-related problems and reducing
waste”.2
Disease-modifying anti-rheumatic drug (DMARD) with
active moderate-severe rheumatoid disease lasting > 12
weeks.
Bisphosphonates in patients taking maintenance oral
corticosteroid therapy.
Calcium and Vitamin D supplement in patients with known
It is commonly agreed that older people are at greater risk of adverse
effects from their medicines due to age related changes in their major
osteoporosis (radiological evidence or previous fragility
fracture or acquired dorsal kyphosis).
organs which in turn alter pharmacokinetics and pharmacodynamics.
They also often have multiple co-morbidities leading to drug-drug
NICE TA160 and TA161 cover prevention of
interactions or cautions and contraindications to preferred treatments.
osteoporosis.
In primary prevention, women aged 75 and over do not
These patients however are often excluded from drug trials making it
require a DEXA scan before starting alendronic acid if they
difficult for the clinician to weigh up the benefits versus risks, let alone
have two or more clinical risk factors or indicators of low BMD;
explain them to the patient. Furthermore, although with increasing age
for secondary prevention this is reduced to one or
a patient can move from benefiting from a treatment to being at
more.
significant risk from it, there can be difficulty in stopping medication for
For treatments other than alendronic acid a DEXA
the fear of being accused of ageism.
scan is required because the treatments are only
This document is based on the STOPP START Tool a medication review
tool designed to identify medication where the risks out weigh the
benefits in the elderly and vice versa.
indicated at certain T scores; unless, in secondary
prevention, the clinician considers it inappropriate
or unfeasible.
In 2011 concerns were raised about cardiovascular risks of
calcium and vitamin D supplements. The MHRA13 issued
guidance that the data limitations meant that there should be
Eighteen experts in geriatric pharmacotherapy initially contributed to
no change to current practice.
suggesting and then rating the criteria. The STOPP criteria were
There were also reports of atypical fractures with long term
3
evaluated (along with Beer’s criteria ) against hospital admissions —
bisphosphonate therapy. The MHRA advice was to periodically
one third of the patients with “potentially inappropriate prescriptions”
review the benefits and risks, particularly after 5 years therapy.
4
25
Musculoskeletal System
according to STOPP criteria presented with an associated adverse drug
event.
BNF Chapter 10
All recommendations from the STOPP START Tool are included here, and
STOPP
Non-steroidal anti-inflammatory drug (NSAID)
with history of peptic ulcer disease or gastrointestinal bleeding, unless
with concurrent histamine H2 receptor antagonist, PPI or misoprostol
where space allows, local and national guidance (in blue-edged boxes)
these can only be considered correct at time of publication.
The tool was validated in patients aged 65 and over but there is still a
(risk of peptic ulcer relapse).
place for clinical judgement in deciding whether a person is “elderly” in
with moderate-severe hypertension
terms of the potential effects of medication.
(moderate: 160/100mmHg – 179/109mmHg; severe: ≥180/110mmHg)
(risk of exacerbation of hypertension).
The recommendations are grouped according to the main British National
with heart failure (risk of exacerbation of heart failure).
Formulary chapters4 with the STOPP items on the left (coloured red) and
with warfarin (risk of gastrointestinal bleeding).
the START items (coloured green) on the right of the double page. The
with chronic renal failure - estimated GFR 20-50ml/min. (risk of
deterioration in renal function).
Long-term use of NSAID (>3 months) for relief of mild joint pain in
osteoarthritis (simple analgesics preferable and usually as effective for
pain relief).
Long-term NSAID or colchicine for chronic treatment of gout where
there is no contraindication to allopurinol (allopurinol first choice
prophylactic drug in gout).
Long-term corticosteroids (>3 months) as monotherapy for
rationale for the intervention is given in italics.
The process of medication review is covered in the practice guide to
clinical medication review.5 As well as using the list of drugs here to
decide which might need to be stopped in the frail elderly it should also
be considered if the drug gives daily symptomatic benefit, prevents rapid
worsening of symptoms or replaces a hormone vital for normal function
e.g. thyroxine. If so it should normally be continued.
rheumatoid arthritis or osteoarthritis (risk of major systemic
A study of prescribing in general practice in Scotland6 used a panel of GPs
corticosteroid side-effects).
and pharmacists to develop “prescribing safety indicators” (PSI) to judge
the prescribing against. These were mostly either high risk drug
Prescribing safety indicators: NSAIDs should not be prescribed
in patients with peptic ulcer disease or in patients aged 75 or over
without gastroprotection.
NSAIDs should not be prescribed in patients aged 65+ with eGFR <60 or
combinations (drug interactions) or drug-disease combinations
(contraindications). The indicators not already covered by STOPP are
given in the blue supporting information boxes however it is the clinicians
responsibility to consider other drug interactions or contra-indications not
listed here.
to patients with heart failure.
24
5
The following drugs or drug classes were most often implicated in a UK
study7 looking at cause of admission in two hospitals over a six month
Urogenital System BNF Chapter 7
period (result given as percentage of adverse drug reaction—ADR—
START
related admissions which in turn were 6.5% of all admissions).
1.
NSAIDs including aspirin
29.6%
2.
Diuretics
27.3%
3.
Warfarin
10.5%
4.
ACEI/A2RAS
7.7%
5.
Antidepressants including lithium
7.1%
There is evidence to support the use of pelvic floor muscle
6.
Betablockers
6.8%
training and bladder training ahead of medication (see table
7.
Opiates
6.0%
below).
8.
Digoxin
2.9%
9.
Prednisolone
2.5%
10.
Clopidogrel
2.4%
This study was in patients over the age of 16, but clinicians will recognise
that these drugs are commonly prescribed in older people.
NICE CG40 Urinary incontinence in women
Immediate release oxybutinin should be offered to women with
OAB or mixed UI if bladder training has been ineffective. There is
no evidence of clinically significant differences between the
antimuscarinic drugs.
OAB: overactive bladder syndrome
UI: urinary incontinence
The authors suggested that over 70% of the ADRs were avoidable. These
findings are supported by a 2006 systematic review8 which found the four
Manage conservatively
most common drug groups associated with preventable drug-related
admissions to be antiplatelets (16%), diuretics (15.9%), NSAIDs (11%)
and anticoagulants (8.3%). In addition to those listed above, they found
drugs used in diabetes (3.5%), positive inotropes (3.2%), calcium
channel blockers (2.8%) and antiepileptics (2.3%) were also implicated.
(This review was not confined to the UK population and not all studies
were specific to older people).
Pelvic floor
muscle training
Stress
UI
Mixed
UI
*
*
*
*
Antimuscarinic
treatment
*
*
might be prudent to tackle the above drugs as a priority after removing
ineffective or unnecessary treatment.
23
First
pregnancy
*
Bladder
training
If wanting to reduce the burden of polypharmacy in gradual steps it
6
Urge
UI or
OAB
Urogenital System BNF Chapter 7
STOPP
Bladder antimuscarinic drugs*
with dementia (risk of increased confusion, agitation).
with chronic glaucoma (risk of acute exacerbation of
glaucoma).
with chronic constipation (risk of exacerbation of
constipation).
with chronic prostatism (risk of urinary retention).
Many anticholinergic (antimuscarinic) drugs are included in the STOPP
sections already but as combining anticholinergic drugs increases the risk
of side effects (including confusion, falls and death) the Anticholinergic
Cognitive Burden scale9 for some commonly prescribed drugs is given on
page 26 and in more detail in the appendices of the practice guide to
clinical medication review.5
Particular caution should be taken if considering stopping the following
drugs (continue treatment, gradual withdrawal or specialist advice before
stopping):10
ACEI and diuretics used in heartfailure.
Amiodarone, CCBs, betablockers or digoxin used to control heart
rate or rhythm.
Alpha-blockers
in males with frequent incontinence i.e. one or more episodes
of incontinence daily (risk of urinary frequency and worsening
of incontinence).
with long-term urinary catheter in situ i.e. more than 2
Anticonvulsants used in epilepsy.
Antidepressant, antipsychotic or mood stabilizing drugs.
Antimuscarinic or other drugs used in Parkinson’s disease.
Steroids, DMARDs or immunosuppressant drugs.
months (drug not indicated).
Further information to aid the assessment of benefits versus risks
*Fesoterodine is a “black drug” locally i.e. unsuitable for pre-
scribing as other drugs are preferred. The traffic light prescribing
guidelines are available from the Medicines Management intranet pages.5
Improvement with antimuscarinic drugs is generally small (less
than 20% compared to placebo) so patients may have been tried
on several brands. Even if on a formulary drug consider a drug
holiday to reassess efficacy. There is no reason to expect patches
or slow release versions to be more effective. 5
22
including number needed to treat and number needed to harm
can be found in the appendices of the practice guide.5
Colour Key.
Medication to consider stopping in patients over 65
from the STOPP Tool1
Medication to consider starting in patients over 65
from the START Tool 1
National and local guidance e.g. NICE Guidelines11 or
other supporting/useful information e.g. prescribing
safety indicators (PSI).
7
STOPP: Screening Tool of Older People’s
Endocrine System BNF Chapter 6
potentially inappropriate Prescriptions.1
The following STOPP prescriptions are
START
potentially inappropriate in persons
Metformin with type 2 diabetes +/- metabolic syndrome
aged ≥65 years of age
Gastrointestinal System
BNF Chapter 1
(in the absence of renal impairment—estimated GFR <50ml/
min).
ACE inhibitor or Angiotensin Receptor Blocker in diabetes
Diphenoxylate, loperamide or codeine phosphate
for treatment of diarrhoea of unknown cause* (risk of delayed
with nephropathy i.e. overt urinalysis proteinuria or
micoralbuminuria (>30mg/24 hours) +/- serum biochemical
diagnosis, may exacerbate constipation with overflow
diarrhoea, may precipitate toxic megacolon in inflammatory
bowel disease, may delay recovery in unrecognised
gastroenteritis).
renal impairment—estimated GFR <50ml/min.
for treatment of severe infective gastroenteritis i.e. bloody
(hypertension, hypercholesterolaemia, smoking history).*
Antiplatelet therapy in diabetes mellitus if one or more co
-existing major cardiovascular risk factor present
diarrhoea, high fever or severe systemic toxicity (risk of
exacerbation or protraction of infection).
Prochlorperazine or metoclopramide with Parkinsonism
Statin therapy in diabetes mellitus if one or more coexisting major cardiovascular risk factor present.*
(risk of exacerbating Parkinsonism).
Proton pump inhibitor at treatment dose for peptic ulcer
disease at full therapeutic dosage for > 8 weeks (earlier
*In 2009 The MHRA issued advice that aspirin is not licensed for
discontinuation or dose reduction for maintenance/
prophylactic treatment of peptic ulcer disease, oesophagitis or
GORD indicated).
primary prevention and recent studies supported its use only in
Anticholinergic antispasmodic drugs with chronic
the benefits with vascular disease including diabetes (but also the
constipation (risk of exacerbation of constipation).
risks of gastrointestinal harms).13
secondary prevention. However they did state that the benefits
and risks have to be considered for individual patients particularly
NICE CG 67 Lipid Modification Prescribing Guidelines re primary
prevention say that diabetics should be considered at high risk.
Review enteral nutrition:
NICE CG32 (Nutrition support in
adults) recommends assessment using a tool such as MUST:
www.bapen.org.uk/pdfs/must/must_full.pdf
8
NICE CG 66 Type 2 Diabetes says that patients over 40 years
should be offered a statin irrespective of CVD status (based on
the cost effectiveness of simvastatin).
21
Endocrine System BNF Chapter 6
STOPP
Glibenclamide or chlorpropamide with type 2 diabetes
mellitus (risk of prolonged hypoglycaemia).
Beta-blockers in those with diabetes mellitus and frequent
hypoglycaemic episodes i.e. > 1 episode per month (risk of
masking hypoglycaemic symptoms).
START: Screening Tool to Alert doctors to Right
i.e. appropriate, indicated Treatments.1
These START medications should be considered
for people ≥ 65 years of age with the following
conditions, where no contraindication exists.
Gastrointestinal System BNF
Chapter 1
Proton Pump Inhibitor with severe gastro-oesophageal acid
Oestrogens
with a history of breast cancer or venous thromboembolism
(increased risk of recurrence)
without progestogen in patients with intact uterus (risk of
endometrial cancer).
NICE CG87 Type 2 Diabetes covers:
reflux disease or peptic stricture requiring dilatation.
Fibre supplement for chronic, symptomatic diverticular
disease with constipation.
NICE CG59 Osteoarthritis
-offering lifestyle advice as well as medication to
“Offer a standard NSAID...Co-prescribe with a
achieve individually set HbA1c levels (and not to
proton pump inhibitor”
pursue highly intensive management to levels of
less than 6.5%)
-self monitoring of blood glucose only when it can be used as
Local dyspepsia and gastric ulcer prescribing guidelines are avail-
part of the overall management
able from the Medicines Management intranet pages.5
-which medication to use
* For diarrhoea of unknown cause consider the possibility of
Prescribing safety indicators: Glitazones should not
Clostridium difficile infection (CDI) if there is a history of antibiotic
be used in heart failure. The BNF advises caution prescribing
use or recent hospital discharge.
glitazones in the elderly because of increased risk of fracture,
bladder cancer and heart failure.
20
Stop antimotility agents and PPIs
Stop antibiotics
9
Cardiovascular System BNF Chapter 2
STOPP
Central Nervous System
BNF Chapter 4
START
Digoxin at a long-term dose > 125µg/day with impaired
renal function — estimated GFR <50ml/min (increased risk
of toxicity).
Levodopa in idiopathic Parkinson’s disease with definite
functional impairment and resultant disability.
Loop diuretic
for dependent ankle oedema only i.e. no clinical signs of
heart failure (no evidence of efficacy, compression hosiery
Antidepressant drug in the presence of moderate-severe
depressive symptoms lasting at least three months.
usually more appropriate).
as first-line monotherapy for hypertension (safer, more
effective alternatives available).
Thiazide diuretic with a history of gout (may exacerbate
gout).
NICE CG42 Dementia covers the use of acetylcholinesterase
inhibitors (AChEIs) and memantine in dementia. They should be
started by a specialist and reviewed by a specialist team to ascertain if it
Beta-blocker
in combination with verapamil (risk of symptomatic heart
is worthwhile continuing them.
block).
Acetylcholinesterase inhibitors are indicated in mild to moderate
Non-cardioselective beta-blocker with Chronic
Alzheimer’s Disease (AD).
Obstructive Pulmonary Disease (COPD) (risk of
bronchospasm).
Memantine is indicated in moderate AD if AChEIs are contraindicated or
not tolerated and is indicated in severe AD.
Calcium channel blockers
with chronic constipation (may exacerbate constipation).
In elderly patients with dementia, antipsychotic drugs are associated
Use of diltiazem or verapamil with NYHA Class III or IV
with a small increased risk of mortality and an increased risk of stroke or
heart failure (may worsen heart failure).
Vasodilator drugs known to cause hypotension in those
with persistent postural hypotension i.e. recurrent >
20mmHg drop in systolic blood pressure (risk of syncope,
falls). Stop if patient has fallen in past 3 months.
transient ischaemic attack. Furthermore, elderly patients are particularly
susceptible to postural hypotension and to hyper- and hypothermia in hot
or cold weather.5
Cumbria Partnership Trust guidance on treating BPSD
(behavioural and psychological symptoms in patients with dementia) are
available from the Medicines Management intranet pages.5
10
19
Central Nervous System
BNF Chapter 4
Aspirin
with a past history of peptic ulcer disease without histamine
Further information:
H2 receptor antagonist or Proton Pump Inhibitor (risk of
bleeding).
at dose > 150mg day (increased bleeding risk, no evidence
Welsh MeReC gives guidance on stopping benzodiazepines,
antidepressants and antipsychotics available at
www.wemerec.org.
for increased efficacy).
with no history of coronary, cerebral or peripheral arterial
symptoms or occlusive arterial event (not indicated).
to treat dizziness not clearly attributable to cerebrovascular
Patient.co.uk has both patient information and professional
disease (not indicated).
resources on stopping benzodiazepines.
with concurrent bleeding disorder (high risk of bleeding).
Warfarin
For
palliative care the website www.gp-
for first, uncomplicated deep venous thrombosis for longer
palliativecare.co.uk contains local information e.g. NHS
than 6 months duration (no proven added benefit).
Cumbria End of Life Strategy and national guidance.
for first uncomplicated pulmonary embolus for longer than 12
months duration (no proven benefit).
with concurrent bleeding disorder (high risk of bleeding).
Use of aspirin and warfarin in combination without
gastroprotection (avoid cimetidine because of interaction with
warfarin)( high risk of gastrointestinal bleeding).
WHO analgesic ladder:
Mild Opioid: codeine, dihydrocodeine, tramadol.
Strong opioid: morphine, diamorphine, buprenorphine, oxycodone, pethidine, tramadol—at high doses.
Clopidogrel
with concurrent bleeding disorder (high risk of bleeding).
Dipyridamole
as monotherapy for cardiovascular secondary prevention (no
evidence for efficacy except in ischaemic stroke).
with concurrent bleeding disorder (high risk of bleeding).
Prescribing safety indicators: The combination of NSAIDs,
ACEI/A2RA and diuretic is considered particularly risky. Antiplatelets
should not be combined with warfarin—even if indicated the benefits
are unlikely to outweigh the harms in the frail elderly.
18
11
Selective serotonin re-uptake inhibitors (SSRI’s) with a history
NICE CG36 Atrial Fibrillation (AF)
When to start warfarin or aspirin in AF:
of clinically significant hyponatraemia (<130mmol/l within the
previous 2 months).
Patients with AF
• Previous
ischaemic
stroke/TIA or
thromboembolic
event
• Age >75 with
hypertension,
diabetes or
vascular disease
Opiates
Moderate
risk:
Low risk:
• Age >65 with
no moderate or
high risk factors
• Age <65 with
no high risk
factors
• Age <75 with
hypertension,
diabetes or
vascular
disease
i.e. chlorphenamine, cyclizine, promethazine (risk of sedation and
anti-cholinergic side effects).
Determine stroke/thromboembolic risk
High risk:
First generation antihistamines if prolonged use (> 1 week)
Use of long-term strong opiates as first line therapy for mildmoderate pain
(WHO analgesic ladder not observed—more details page 16).
Patients with AF
• Clinical evidence
Determine stroke/thromboembolic risk
of valve disease,
heart failure, or
impaired left
ventricular function
High
Moderate
on
risk
risk
echocardiography
Regular opiates for more than 2 weeks in those with chronic
constipation without concurrent use of laxatives (risk of severe
constipation).
long-term in those with dementia unless for palliative care or
Low
risk
management of chronic pain syndrome (exacerbation of cognitive
impairment).
long-term in those with recurrent falls (risk of drowsiness, postural
Consider anticoagulation
Contraindications to
warfarin?
Consider anticoagulation
or aspirin
Aspirin 75 to 300 mg/day
if no contraindications
YES
NO
Reassess risk stratification
whenever individual risk
factors are reviewed
Warfarin, target INR = 2.5
(range 2.0 to 3.0)
hypotension, vertigo).
NICE CG90 Depression in Adults:
The first step in mild depression is not routinely to prescribe e.g.
offer cognitive behavioural therapy (CBT).
Prescribing safety indicators: The combination of tricyclic
NICE TA 210 covers which antiplatelet to use to prevent occlusive
vascular events e.g. MI use aspirin first line; ischaemic stroke
use clopidogrel first line and TIA use MR dipyridamole AND aspirin.
antidepressants and heart failure is considered risky (reduced
contractility and pro-arrhythmic).12
*When reviewing antipsychotics the original diagnosis must be
carefully considered—if for psychosis then benefit may well outweigh
risks. See also page 19—dementia.
12
17
Central Nervous System
Cardiovascular System BNF Chapter 2
BNF Chapter 4
START
STOPP
Tricyclic antidepressants (TCAs)
with dementia (risk of worsening cognitive impairment).
with glaucoma (likely to exacerbate glaucoma).
with cardiac conductive abnormalities (pro-arrhythmic effects).
with constipation (likely to worsen constipation).
with an opiate or calcium channel blocker (risk of severe
constipation).
with prostatism or prior history of urinary retention (risk of urinary
retention).
Warfarin in the presence of chronic atrial fibrillation (see NICE
guidance on page 12).
Aspirin in the presence of chronic atrial fibrillation, where warfarin
is contraindicated, but not aspirin.
Aspirin with a documented history of atherosclerotic coronary
disease in patients with sinus rhythm.
Clopidogrel with a documented history of ischaemic stroke or
peripheral vascular disease
Antihypertensive therapy where systolic blood pressure
consistently >160 mmHg.
Statin therapy with a documented history of coronary, cerebral or
Benzodiazepines
if long-term (i.e. > 1 month) and long-acting
e.g. chlordiazepoxide, flurazepam, nitrazepam and
benzodiazepines with long-acting metabolites e.g. diazepam (risk
of prolonged sedation, confusion, impaired balance, falls).
if fallen in past 3 months
peripheral vascular disease, where the patient’s functional status
remains independent for activities of daily living and life expectancy is
> 5 years.*
Angiotensin Converting Enzyme (ACE) inhibitor with chronic
heart failure.
ACE inhibitor following acute myocardial infarction.
Antipsychotics*
long-term (i.e. > 1 month) as hypnotics (risk of confusion,
Beta-blocker with chronic stable angina.
hypotension, extra-pyramidal side effects, falls).
long-term ( > 1 month) in those with parkinsonism (likely to
worsen extra-pyramidal symptoms).
if fallen in past 3 months (may cause gait dyspraxia,
Parkinsonism).
Phenothiazines in patients with epilepsy (may lower seizure
threshold).
*NICE CG 67 Lipid Modification Prescribing Guidelines do not specify a
degree of independence or life expectancy for secondary prevention
(offer to all adults with clinical evidence of CVD); in primary prevention
they suggest systematic strategies are used to identify people aged 4074 likely to be at high risk— statins can be started in older people but
Anticholinergics to treat extra-pyramidal side-effects of
risk calculators are inaccurate, they may be at greater risk from the
antipsychotic medications (risk of anticholinergic toxicity).
treatment and benefit is unlikely to be gained until after five years of
therapy.
16
13
Respiratory System BNF Chapter 3
Respiratory System BNF Chapter 3
STOPP
Theophylline as monotherapy for COPD (safer, more
effective alternatives; risk of adverse effects due to narrow
therapeutic index).
START
Regular inhaled beta 2 agonist or anticholinergic
(antimuscarinic) agent for mild to moderate asthma or
COPD.
Systemic corticosteroids instead of inhaled corticosteroids
for maintenance therapy in moderate-severe COPD
Review patients with mild or moderate COPD at least once a
(unnecessary exposure to long-term side-effects of systemic
steroids).
year and severe or very severe COPD (FEV1 <50% predicted)
Nebulised ipratropium with glaucoma (may exacerbate
treatment selection for COPD. (Use BTS/SIGN guidelines for
glaucoma).
asthma).
at least twice a year. Follow NICE guidance regarding
First generation antihistamines (sedative, may impair
sensorium). Stop if patient has fallen in past 3 months .
NICE CG 101 COPD
NICE CG 101 COPD
Theophylline
Assess the need for oxygen therapy in people with any of the
Only offer theophylline after trials of short- and long-
following:
acting bronchodilators or to people who cannot use
-very severe airflow obstruction (FEV1 <30% predicted)
inhaled therapy.
-cyanosis
-polycythaemia
Oral Corticosteroids
-peripheral oedema
Maintenance use of oral corticosteroid therapy in COPD is not
-raised jugular venous pressure
normally recommended.
-oxygen saturations less than or equal to 92% breathing air.
Some people with advanced COPD may need maintenance oral
corticosteroids if treatment cannot be stopped after an exacerbation.
Give people with FEV1 < 30% a course of antibiotic and oral
Keep the dose as low as possible, monitor for osteoporosis and offer
corticosteroid tablets to keep at home.
prophylaxis.
14
15